The mnemonic DR C BRAVADO is a systematic approach to the interpretation of FHR tracings for both CEFM and SIA (Structured Intermitent Auscultation).

Determine Risk

Contractions

Baseline RAte

Variability

Accelerations

Decelerations

Overall Assessment

Category I Fetal Heart Rate tracings

Category I tracings are normal tracings that are strongly predictive of normal fetal pH status at the time of observation and must include all of the following:

baseline of 110 to 160 bpm

moderate baseline variability [meaning 6 to 25 bpm amplitude range]

late or variable decelerations are absent

early decelerations may be present or absent

accelerations may be present or absent

Generally, Category I tracings are considered normal and can be followed routinely.

Category II Fetal Heart Rate tracings

Indeterminant tracings are not predictive of fetal acid-base status and cannot be classified as either I or III. The presence of moderate variability or accelerations is highly predictive of normal fetal acid-base status. These tracings require prompt evaluation and efforts to resolve the tracing. Category II tracings may show any of the following:

tachycardia

baseline with absent, minimal, or marked variability

recurrent variable decelerations with minimal to moderate variability

recurrent late decelerations with moderate variability

variable decelerations with slow return overshoot or “shoulders”

prolonged deceleration

no acceleration after fetal stimulation

Category II tracings are indeterminate and not predictive of abnormal pH status. These tracings require prompt evaluation and efforts to resolve the tracing.

Category III Fetal Heart Rate tracings

These tracings are predictive of abnormal fetal pH status. These require prompt evaluation and consideration of immediate delivery. These include:

sinusoidal pattern

Or

absent fetal heart rate variability with any of the following:

recurrent late decelerations

recurrent variable decelerations

bradycardia

These tracings [the above] are predictive of abnormal fetal pH status. These require prompt evaluation and consideration of immediate delivery.

Documentation of fetal heart tracing and categorization during labor should include:

Various intrauterine resuscitative measures for category II or category III tracings or both

Potential interventions:

initiate lateral positioning (either left or right)

administer maternal oxygen

administer intravenous fluid bolus

reduce uterine contraction frequency

discontinue oxytocin or cervical ripening agents

administer tocolytic medication (e.g., terbutaline)

initiate maternal repositioning

initiate amnio infusion

if prolapsed umbilical cord is noted, elevate the presenting fetal part while preparations are underway for operative delivery

And always check the cervix and the maternal vital signs [including oximetry]

Ancillary testing for Category II and III fetal heart rate tracings

Fetal scalp pH testing is no longer commonly performed in the United States and has been replaced with fetal stimulation or immediate delivery (by operative vaginal delivery or if necessary cesarean section). A meta-analysis showed that if there is absent or minimal variability without spontaneous accelerations, the presence of an acceleration after scalp stimulation or fetal acoustic stimulation indicates that the fetal pH is greater than 7.20. If the fetal heart tracing remains abnormal then these tests the may need to be performed periodically and consideration for emergent cesarean or operative vaginal delivery is usually recommended. Cord blood gases are recommended after a delivery for an abnormal heart tracing.